Administrative Review Summary Report

Date:  02-14-20

Name of Agency:  St. John Christian Heritage Academy

            Date of off-site review: 12-05-19

Reviewer:  Matthew Smith                                                     Date of on-site review: 01-21-20

 & 01-23-20

Persons interviewed:  Penny Emery                                      Date of exit conference: 01-23-20

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

• Afterschool Snack Program:  The SFA failed to conduct the first or two self-inspections within the first four weeks of school [7 CFR Part 210.9 (c) (7)]. Prior to the On-Site visit the SFA conducted the first self-inspection.
  
• Civil Rights: The School Food Authority (SFA) did not provide documentation of the most recent annual civil rights training at the time of the Off-Site visit.  FNS Instruction 113-1 requires staff members who work with program applicants or participants to receive annual civil rights training.  Prior to the On-Site visit this training was conducted and documentation was provided to the State Agency (SA) reviewer.
  
  At the time of the Off-Site visit the SFA had an out of date non-discrimination statement on the monthly meal menu [FNS Instruction 113-1].  Prior to the On-Site visit the SFA took corrective action by putting the current version of the non-discrimination statement.
   
• Failure to provide requested records:  The SFA failed to provide documentation as required by their State Agency Agreement and a 7 CFR Part 210.9 (b) (17).  Prior to the On-Site visit the SFA provided the requested documentation requested as part of this AR.
  
• Meal Patterns:  During the menu week assessment of breakfast and lunch menus for the week of 11/04/19 through 11/08/19 systemic insufficient serving sizes were discovered [7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)].  The SFA took corrective action bringing all insufficient serving sizes into compliance with the meal patterns for the week being assessed, as well as for the review period. 

The lunch menus failed to meet the weekly vegetable subgroup servings for the following subgroups: the red/orange vegetable subgroup, the dark green vegetable subgroup, and starchy vegetable subgroup [7 CFR Part 210.10 (c)].  Prior to the completion of the On-Site AR the SFA took corrective action bringing the menu week into compliance with the meal pattern.

The SFA offered an unallowable milk type [low-fat (2%)] at breakfast and lunch during the assessed menu week and review period [7 CFR Part 210.10 (d) and 7 CFR Part 220.8 (d)].  The SFA took immediate corrective action during the Off-Site AR, ceasing the use of the unallowable milk type.

The SFA failed to offer a variety of milk types to students at breakfast and lunch [7 CFR Part 210.10 (d) and 7 CFR Part 220.8 (d)]. Prior to the completion of the On-Site AR the SFA took corrective action by offering a variety of milk types at all reimbursable meals.

The assessed breakfast and lunch menus failed to meet the bread/grain requirement of at least half the weekly serving be Whole Grain-Rich [7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)].  Prior to the completion of the On-Site AR the SFA took corrective action bringing the weekly servings into compliance.

Due to the violations described above; our office has no choice but to remove the 7 cents, per lunch, performance-based reimbursement beginning with February's claim [as required by 7 CFR Part 210.18 (g)].

Due to your willingness to quickly take corrective action we are excising our discretion to not apply fiscal action to the above insufficient servings sizes as allowed for under 7 CFR Part 210.18 (g) (2).

• Professional Standards:  The school food services director did not completed eight hours of food safety training within 30 days of hire or within five years of the date of hire [7 CFR Part 210.31 (b) (2)].  Prior to the completion of the Off-Site AR the director completed eight hours of food safety.

Corrective actions for the above were made prior to the On-Site AR.No further action is required for the above.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted December 5, 2019:

Civil Rights:  The public release printed in the Oklahoma City Herald did not contain all of the required areas, or have the current USDA approved non-discrimination statement.  FNS Instruction 113-1 requires the public release to contain the following:

• The income guidelines for free and reduced meals for the school year that the public release is for.
• The current USDA approved non-discrimination statement.  During this Off-Site portion of this review the SFA was provided with the current approved non-discrimination statement.
• The release must explain households will be notified of their children's eligibility for free meals if the members of the household are receiving assistance [Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Family (TANF), or The Food Distribution Program on Indian Reservations (FDPIR)].
• The release must explain that a child or another household member's receipt of benefits from assistance programs (SNAP, TANF, or FDPIR) extends the eligibility to all children who are members of the household.
• The release must explain no further application is required for free meals if the household is notified that the children are directly certified.

Prior to the beginning of each school year our office emails out a prototype of the public release that contains all of the above areas.

7 CFR Part 245.5 requires SFAs to publicly announce their public release at the beginning of the school year.  The public release should be sent to local media (for example the local newspaper).

To demonstrate compliance with the civil rights local wellness policy:

• Provide St. John Christian Heritage Academy's (SJCHA) plan for corrective action to demonstrate compliance and understanding. 

Local Wellness Policy: The SFA's local wellness policy needs to have the following added:

• The policy needs to have goals for other school based activities [7 CFR Part 210.31 (c) (1)].  The goals for other school based activities should have their own section of the policy.  Examples of other school based activities include (but are not limited to):

• Promote health and wellness by hosting health fairs, theme weeks, and guest speakers promoting a healthy lifestyle.
• Wellness activities conducted as part of the Afterschool Snack Program.

• The policy needs to have guidelines and standards for the marketing of food and beverages sold on campus during the school day [7 CFR Part 210.31 (c) (6)].
• The policy needs to have a description for the measuring of the implementation of the policy [7 CFR Part 210.31 (c) (6)].

At the time of the Off-Site the local wellness policy was not posted publicly as required by 7 CFR Part 210.31 (d) (2).  This requirement can be met by posting the policy on a public bulletin board, or on the school's website.

The SFA failed to provide documentation of the most recent assessment and update their local wellness policy.  USDA Memo SP24-2017 requires the assessment and update to be documented on a wellness assessment report.  During the Off-Site portion of this review the Reviewer emailed a prototype triennial wellness assessment report on 12/06/19.  This report can be used to meet this requirement.  7 CFR Part 210.31 (e) (2) requires local wellness policies to be assessed at least once every three years.  The triennial wellness assessment report documenting the assessment and update to the policy must be posted publicly [as required by 7 CFR Part 210.31 (e) (2)].  This report should be posted with the local wellness policy.

To demonstrate compliance with the local wellness policy:

• Add the following to the local wellness policy:

• The goals for other school based activities
• The guidelines and standards for the marketing of food and beverages on campus during the school day
• A description for the measuring of the implementation of the policy

• Provide a copy of the updated local wellness policy with the required changes listed above.
• Provide a copy of the triennial wellness assessment report for the SFA's local wellness policy.
• Publicly post the updated local wellness policy and the triennial wellness assessment report.
• Provide the above requested documentation along with SJCHA's plan for corrective action to demonstrate compliance and understanding.   

Resource Management – End of School Year Revenue and Expense Report and Unallowable Expenses Charged to the Nonprofit School Food Services Account (NSFSA):  SJCHA did not conduct the end of school year review of total revenue and expense for school year 2018-2019. Documentation of the school food services account's nonprofit status as required by 7 CFR Part 210.14 (a), 7 CFR Part 210.14 (b) and 7 CFR Part 210.19 (a) (1).  This review allows SFA's to ensure costs incurred to the account are necessary, reasonable, and allowable. During the Off-Site portion an end of school year revenue and expense report was provided.

Unallowable expenses were also charged to the NSFSA.  The SFA charged the renewal of the daycare license, as well as a print job for a fund raiser not related to the school food services the NSFSA.  Both of expenses are unallowable.  7 CFR Part 210.14 (a) requires "revenues received by the nonprofit school food service are to be used for the operation or improvement of such food service."  Examples of allowable expenses are (but not limited to) program food and supplies. 

The NSFSA must be reimbursed for unallowable expenses.  This reimbursement cannot be made with revenue generated by your school's school nutrition programs, and, or other federal funds.

To demonstrate compliance with Resource Management – End of School Year Revenue and Expense Report and Unallowable Expenses Charged to the NSFSA:

• Provide documentation demonstrating the NSFSA was reimbursed for the unallowable expenses.
• Provide the above documentation along with SJCHA's plan for corrective action demonstrating compliance and understanding.

Resource Management – Internal Controls:SJCHA did not have internal controls in place to ensure only allowable expenses are charged to the NSFSA.  Federal regulation, 2 CFR Part 200.303 requires SFAs to have internal controls in place to ensure only allowable expenses are charged to the NSFSA.  The following are some examples of internal controls:

• Training financial staff on financial management to include allowable expenses (must be documented).
• Written policy prohibiting funds from the NSFSA from being used to cover bad debt.
• Only charging allowable expenses to the NSFSA [such as food, program supplies, and food services staff wages (provided they have no duties outside the food services program)].

To demonstrate compliance with Resource Management – Internal Control Requirements:

• Provide SJCHA's plan for corrective action demonstrating compliance and understanding.

Resource Management – Adult Meals:  SJCHA was providing free meals to staff members who did not have duties with in the SFA's school nutrition programs.  FNS Instruction 782-5 Rev. 1 specifies, "SFAs must ensure those federal reimbursements, children's payments, USDA donated foods, and other revenue from the SFA's school food services program do not subsidize program meals served to adults."  SJCHA must reimburse the NSFSA for all adult meals served during the review period (November 2019).  This reimbursement cannot be made with revenue generated by school nutrition programs, and or other federal funds.

To demonstrate compliance with Resource Management – Adult Meals:

• Provide documentation of the reimbursement of the NSFSA for the adult meals provided to staff for the month of November 2019.
• Provide the above requested documentation along with SJCHA's plan for corrective action demonstrating compliance and understanding.

Resource Management – Loan Repayment:During school year 2018-2019, SJCHA repaid a loan from the general fund to cover deficits in the NSFSA [7 CFR Part 210.10 (c)].  SJCHA did not have a loan agreement prior to the loan being made from the general fund to cover the deficits in the NSFSA.  

The USDA requires SFAs to have a written loan guarantee in place before any funds are transferred.  This agreement to include language stating the loan will be repaid provided there are sufficient funds to do so.  The SFA is required to keep records of the loan agreement, documentation of the funds being transferred to the NSFSA from the general fund, and documentation of the loan repayment from the NSFA.  7 CFR Part 210.15 (b) (7) requires SFAs to retain those resource management records for three years plus the current school year.  

To demonstrate compliance with Resource Management – Loan Repayment:

• Provide SJCHA's plan for corrective action demonstrating compliance and understanding.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted January 21, 2020 and January 23, 2020:

Counting and Claiming: On the first day of the On-Site visit, January 23, 2020, St. John Christian Heritage Academy was not conducting a point of service count for the breakfast meals. 

State Agency (SA) reviewer was told the breakfast meal counts are taken when the students arrive for before school care, and then they're sent to the cafeteria for their breakfast meal.   Federal regulations [7 CFR Part 210.9 (b) (9) and 7 CFR Part 220.11 (d)] and SJCHA's meal count and collection procedure agreement requires SJCHA to only use point of service meal counts.  

This is a systemic counting error and Performance Standard I Violation (PSI) [7 CFR Part 210.18 (g) (1) (ii)], requiring fiscal action. SJCHA took immediate corrective action by having the staff member who runs the before care program for SJCHA to conduct a point of service meal counts for the daily breakfast meal service.

A review of the counting system demonstrates systemic counting errors for the review period (November 2019), which results in a PSI violation, 7 CFR Part 210.18 (g) (1) (ii).  Systemic errors were found for breakfast, lunch, and snack.  The daily meal counts and snack counts were not calculated correctly.  

The errors are a result of SJCHA not using an edit check, thus causing a miss-calculation of the November meal counts for breakfast, lunch, and snack.  7 CFR Part 210.8 (a) (3) and 7 CFR Part 220.11 (d) requires SFA's to complete an edit check daily for breakfast, lunch, and snacks.

The edit check compares the daily attendance and daily meal count for each eligibility category.  If the daily meal count for any of the eligibility category exceeds the daily attendance, this indicates a problem with the count for the category.  If an electronic edit check is used, such as the Excel spreadsheet provided by our office via email on January 22, 2020, the spreadsheet will automatically add the daily meal counts up for each eligibility category for the month.  Use of this spreadsheet will reduce the chance of error due to manually calculating the daily and monthly meal counts.

Below are the differences identified in SJCHA's November lunch counts, when comparing the meal roster to the meals listed on the claim:

 

Free meals were over claimed by 17 meals and paid meals were under claimed by 15 meals.

Below are the differences identified in SJCHA's November school breakfast counts, when comparing the meal roster to the meals listed on the claim:

Free meals were under claimed by one meal and paid meals were over claimed by one meal.

Below are the differences identified in SJCHA's August Afterschool Snack Program counts, when comparing the meal roster to the meals listed on the claim:

Free snacks were over claimed by 12 free snacks and two paid snacks.

At the time of the On-Site AR Reviewer strongly recommended SJCHA use an electronic edit check to reduce chance of errors occurring on futures reimbursement claims.    

To demonstrate compliance with counting and claiming:

• Continue only taking point of service counts.
• Review the counting and claiming system and create a plan to ensure accurate daily meal counts are taken and recorded.
• Begin using an electronic edit check daily to record meal counts.
• Provide copies of the following: SJCHA's meal rosters for February 2020, SJCHA's edit check forms, and the claim for February 2020.
• Provide the above copies, along with SJCHA's corrective action plan to demonstrate compliance and understanding.

Meal Patterns:  A review of the production records revealed insufficient servings of the daily required fruit serving.  The reviewer provided technical assistance and requested SJCHA increase the fruit serving size for all breakfast meals to 1 cup.  The SA Reviewer verified the corrective action was made during the On-Site visit.

A review of the production records also revealed a day where the breakfasts were served without fruit.  7 CFR Part 220.8 (c) requires 1 cup of fruit at breakfast meals.  The missing meal component results in a Performance Standard 2 (PS2) violation, requiring fiscal action, 7 CFR 210.18 (g) (2).

The Breakfast Meal Pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes for grades K-5; 1 oz. by weight bread/grain daily and 7-10 oz. per week, 1 cup of fruit daily and 5 cups per week, and 1 cup fluid milk (choice between fat free and 1% flavored or unflavored, one choice must be unflavored) daily and 5 cups per week.

To demonstrate compliance with meal patterns:

• Review SJCHA's menus for compliance with the meal patterns for grades K-5 for breakfast and lunch [7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)].
• Provide SJCHA's corrective action plan to demonstrate compliance and understanding.

Record Keeping:  During the review SJCHA had problems locating requested documentation.  7 CFR Part 210.23 (c) requires SFAs to retain all records for three years after the date of submission of the final financial status report for the fiscal year.

SJCHA could not locate the documentation for the most recent verification completed in November of 2019. 

To demonstrate compliance with record keeping:

• Start retaining the records for three years after the date of submission.
• Provide SJCHA's corrective action plan to demonstrate compliance and understanding.

Procurement Review Summary Report

Date:  02-14-20

Name of Agency:  St. John Christian Heritage Academy

            Date of AR off-site review: 12-05-19

Reviewer:  Matthew Smith                                                     Date of AR on-site review: 01-21-20

 and 01-23-20

Persons interviewed:  Penny Emery                                     Date of exit conference: 01-23-20

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

Findings and Recommendations Identified During the Procurement Review:

Failure to Provide Requested Records:  St. John Christian Heritage Academy (SJCHA) failed to provide documentation as required by their State Agency Agreement and a 7 CFR Part 210.9 (b) (17).  This federal regulation requires SFAs to:

"Upon request make all accounts and records pertaining to its school food service available to the State Agency, and to the USDA Food and Nutrition Service (FNS)"

The SA reviewer made several requests to SJCHA to provide records starting on October 28, 2019 through January 24, 2020.  The following records were not provided:

• The solicitation document sent to vendors during school year 2018-2019.
  

All documentation between school and vendors must be kept.  Proper solicitation documentation (which can be a list of program food and supplies SJCHA wants to procure) ensures all potential vendors are being provided the same information in a fair and competitive manner.  The solicitation documentation should also include the approximate size of your school (students and staff members), so the vendors have enough information to provide an informed response.

To demonstrate compliance with providing requested records:

• Provide SJCHA's corrective action plan to demonstrate compliance and understanding in providing the solicitation documentation.

Procurement Plan:  The procurement plan provided during the AR Off-Site did not include the required price analysis language for procurements above the small purchase threshold ($150,000) as required by  2 CFR Part 200.323 (a).  The plan also failed to cover any formal procurement methods for procurements in excess $150,000.  

To demonstrate compliance with procurement plan requirements:

• Provide a procurement plan that contains how SJCHA would conduct formal procurements to include requirements for SJCHA to conduct a price analysis for procurements above the small purchase threshold.
• Provide the above along with SJCHA corrective action plan to demonstrate compliance and understanding.